From the Guidelines
For this 43-year-old female with recurrent chest pain despite two previous negative cardiac evaluations, the next step should be a comprehensive evaluation focusing on non-coronary causes of chest pain. Given her history of negative stress echo in 2021 and coronary CTA in 2023, the likelihood of coronary artery disease is low 1. The patient's symptoms suggest the need for a thorough investigation into other potential causes of chest pain, including gastrointestinal, musculoskeletal, and psychological factors. I recommend starting with a detailed history and physical examination to better characterize the pain pattern, followed by basic laboratory tests including complete blood count, comprehensive metabolic panel, and thyroid function tests. An ECG should be performed during symptoms if possible. Consider a trial of a proton pump inhibitor such as omeprazole 40mg daily for 2-4 weeks to evaluate for gastroesophageal reflux disease as a potential cause 1. Anxiety assessment using a validated screening tool would also be appropriate. If these evaluations are unrevealing, referral to a gastroenterologist for possible endoscopy and consideration of musculoskeletal causes through physical therapy evaluation may be warranted. The use of long-acting nitrates, calcium channel blockers, or beta blockers may be considered for symptom management, as suggested by previous guidelines 1. However, given the most recent guidelines, a more comprehensive approach focusing on non-coronary causes is preferred 1. Key points to consider in the evaluation include:
- Detailed history and physical examination
- Basic laboratory tests
- ECG during symptoms if possible
- Trial of proton pump inhibitor
- Anxiety assessment
- Referral to gastroenterologist or physical therapy if necessary
- Consideration of long-acting nitrates, calcium channel blockers, or beta blockers for symptom management.
From the Research
Next Steps for the Patient
Given the patient's history of chest pain and negative results from stress echo and coronary CTA, the next steps should consider alternative causes of chest pain.
- The patient's symptoms could be related to gastroesophageal reflux disease (GERD), as studies have shown a relationship between GERD and myocardial ischemia 2, 3, 4, 5.
- Endothelial dysfunction may play a role in the development of GERD in patients with ischemic heart disease, which could be relevant to this patient's condition 5.
- The severity of acid reflux has been linked to esophageal motility, esophagitis, and cardiac morphology in GERD patients, suggesting that an evaluation of these factors may be helpful 6.
- Further evaluation of the patient's symptoms, including an assessment of GERD and its potential impact on cardiac function, may be necessary to determine the cause of the chest pain.
- Consideration of the patient's autonomic nervous system function, as it relates to GERD and cardiac function, may also be relevant 2, 3.